What are the diagnostic changes for separation anxiety disorder across DSM‑III, DSM‑III‑TR (Text Revision), DSM‑IV, DSM‑5, DSM‑5‑TR (Text Revision), and ICD‑10 and ICD‑11?

Evolution of Separation Anxiety Disorder Diagnostic Criteria Across DSM and ICD Versions

DSM-III Through DSM-IV-TR: Childhood-Only Classification

Separation Anxiety Disorder was historically restricted to childhood diagnoses, requiring symptom onset before age 18 years, and was categorized under "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" rather than among the anxiety disorders. 1, 2, 3

• In DSM-IV and DSM-IV-TR, adults experiencing separation anxiety symptoms could only receive a retrospective diagnosis if they could establish onset before 18 years of age 2, 3
• This age restriction meant that adults with separation anxiety were typically misdiagnosed with panic disorder, agoraphobia, or generalized anxiety disorder instead 4
• The childhood-only classification resulted in systematic under-recognition and under-diagnosis of adult separation anxiety disorder 3

DSM-5: The Paradigm Shift to Lifespan Diagnosis

DSM-5 eliminated the age-of-onset restriction entirely and reclassified Separation Anxiety Disorder from the childhood section to the main anxiety disorders chapter, placing it alongside other adult anxiety conditions. 5, 2, 3

Key Changes in DSM-5:

• Removal of age criterion: The disorder can now be diagnosed at any age, with onset in childhood or adulthood 2, 3, 4
• Reclassification: Moved from developmental disorders to the anxiety disorders chapter 5
• Duration criteria: Symptoms must persist for at least 6 months in adults (or 4 weeks in children) 5
• Functional impairment requirement: Clinically significant distress or impairment in social, occupational, or academic domains remains essential 5, 6

This change was driven by epidemiological evidence showing unexpectedly high prevalence in adults (lifetime prevalence of 6.6% in the US), with 20-40% of adult psychiatric outpatients meeting criteria, often with first onset after teenage years 3, 4

DSM-5-TR: Maintained Lifespan Approach

The DSM-5-TR retained the lifespan perspective established in DSM-5, continuing to classify Separation Anxiety Disorder within the anxiety disorders chapter without age restrictions 5

ICD-10: Childhood-Focused Classification

ICD-10 codes Separation Anxiety Disorder as F93.0 and categorizes it within childhood emotional disorders, mirroring the DSM-IV childhood-focused approach. 5

• This classification maintains the traditional view of separation anxiety as primarily a childhood condition 5
• The ICD-10 approach contrasts sharply with the contemporary DSM-5 lifespan perspective 5

ICD-11: Alignment with DSM-5 Lifespan Model

ICD-11 updated its classification to align with the DSM-5 lifespan perspective, retaining a distinct code for Separation Anxiety Disorder while differentiating it from selective mutism (F94.0), specific phobia, social anxiety disorder (F40.10), panic disorder (F41.0), and generalized anxiety disorder (F41.1). 5

• This represents a major shift from ICD-10's childhood-only framework 5
• The change acknowledges that separation anxiety can arise at any age, not always in continuation with childhood disorder 1, 7

Clinical Implications of Diagnostic Evolution

Differential Diagnosis Considerations:

• Normal developmental fears in toddlers must be distinguished from pathological anxiety characterized by excessive, developmentally inappropriate distress that impairs functioning 5, 6
• The disorder must be differentiated from panic disorder with agoraphobia, generalized anxiety disorder, and social anxiety disorder 5

Comorbidity Recognition:

Separation Anxiety Disorder frequently co-occurs with other anxiety disorders, major depressive disorder, and substance-use disorders, requiring comprehensive assessment of comorbid conditions. 5, 6

Impact on Clinical Practice:

• Parents (particularly mothers) of children with separation anxiety disorder who were previously diagnosed with agoraphobia are now more appropriately diagnosed with adult separation anxiety disorder 4
• This focuses attention on intervening with both members of the dyad to overcome mutual reinforcement of symptoms 4
• Adults with separation anxiety disorder manifest high levels of disability and tend to show poor response to conventional treatments, necessitating novel interventions 4

Assessment Tools Developed:

Three specific instruments emerged to assess adult separation anxiety disorder: 1

• Adult Separation Anxiety Structured Interview (ASA-SI): semi-structured interview with items adapted from DSM-IV-TR childhood criteria
• Adult Separation Anxiety-27 (ASA-27): self-administered rating scale
• Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS): structured interview with separate childhood and adulthood forms

Critical Diagnostic Threshold

The core distinction between normal and pathological separation anxiety rests on whether the fear is excessive, developmentally inappropriate, out of proportion to actual threat, and causes clinically significant functional impairment. 5, 6 This criterion applies consistently across all DSM-5, DSM-5-TR, and ICD-11 formulations, representing the fundamental diagnostic threshold that separates disorder from normal developmental variation.